1. Therapeutic Modalities

2. Therapeutic Modalities
exercise (strengthening/stretching)
infrared
heat
cold

3. Therapeutic Modalities
electromagnetic
produce radiant energy
no transmitting medium needed
acoustic
produce sound waves
require a conducting medium
Electromagnetic – similar to intraferential unit
Acoustic – more like an ultrasounds
Gel medium allows ultrasound waves to penetrate skin

4. Choosing a modality type and severity of injury anatomy of the region
indications/contraindications of each
efficacy of a treatment protocol
How well is it working
continual monitoring of progress
Improvements, good, but do not use exact same settings every single time
Do not use stagnant settings – customize treatment program to specific individual situation of the injury

5. Wavelength and Frequency
distance between peaks
Frequency
number of cycles (waves) in one second
Measured in hertz
Wavelength: distance between each peak
Frequency: number of wavelengths in each second. Measured in hertz

6. Contact with tissue Three possible occurrences when energy hits tissue
1- reflected off – nothing gets through
2- refracted/bent
3- absorbed

7. Cryotherapy limited to 1 cm penetration ( likely deeper up to 5 cm ??)
superficial effects
cutaneous blood vessels
cutaneous nerve receptors
cold  stinging  burning/aching  numbness
Crytherapy: application of cold
Likely goes deeper then 1cm of penetration
Also dependant on what type of cryotherapy is being used. Ex: ice cup vs cold tub
Vascular and Nervous responses to cold
4 phases to cold

8. Physiological Responses
 blood flow
due to vasoconstriction of local blood vessels
 inflammation
due to reduced metabolic rate
Vasoconstriction and decreased pain (decrease in Nervous sensation)
Potential decrease in pain
Decreased inflammation due to a decreased metabolic rate

9. Physiological Responses
 muscle spasm
due to  motor nerve conduction velocity and muscle spindle excitability
 pain
due to cold-induced anesthesia

10. Contraindications/ Precautions
hypersensitivity
Raynaud’s disease
patches of altered sensation
ex. from cutaneous nerves severed during surgery
use insulating layer with chemical packs
Hypersensitive to ice
Raynaud’s allergic to ice – physiological responses occur, but the burning sensation that occurs is magnified signifcantly
Altered sensitivity – ex:
Chemical packs are colder then normal ice packs therefore there is an increased chance of frost bite

11. Treatment ice pack ice massage
minutes
every hour during acute phase
ice massage
minutes
until anesthesia occurs
No real benefits for to icing longer then minutes at a time
Just ice repeatedly
Time – accomplish four stages of healing
No real benefits for to icing longer then minutes at a time
Just ice repeatedly
Careful icing certain areas due to nerves being very close to the skin
Lateral Knee – peroneal nerve
Later elbow – ulnar nerve
Can result in nerve damage

12. Cryotherapy

13. Thermotherapy limited to 1 cm penetration superficial effects
cutaneous blood vessels
cutaneous nerve receptors
Cold goes much deeper then heat
Heat before practice, but ice after practice
If an athlete is not practicing at all then use ice for all modalities due to deeper penetration
Ice and heat accomplish similar tasks, but physiologically there are a few minor differences.

14. Physiological Responses
 blood flow
due to vasodilatation of local blood vessels
 metabolism, capillary permeability, leukocytes, phagocytosis
 edema formation**
 lymphatic and venous drainage
Due to increased blood flow

15. Physiological Responses
 pain
due to heat-induced anesthesia
 elasticity of muscles, ligaments, capsule
 muscle spasm

16. Contraindications/ Precautions
acute injuries (active hemorrhaging or swelling)
if infection is present
sensory or circulatory impairment
toweling for protection (5 min. check)
fair skin, red hair*
Acute injuries – will increase edema – due to increase blood flow and metabolism
Infection – tracking causing pain in lymph nodes, puss, redness, potential fever,
Sensory or circulatory impairment – use towels in order to avoid burning or overheating

17. Treatment hydrocollator pack whirlpool 15 - 20 minutes
° C ( ° F)

18. Contrast Baths hot - 104-106° F cold - 50-60° F
for sub-acute swelling
alternate hot and cold immersion
hot ° F
cold ° F
3 (hot) : 1 (cold) or 4 : 1 for 20 min
Also a good way to move an athlete from cold to hot – see how the athlete reacts, but make sure the athlete finishes in the cold tub
Have them do active muscle movements while in the warm tub

19. Ultrasound fetal development cancerous tumors stimulate tissue repair
imaging of internal structures
fetal development
destruction of tissue
cancerous tumors
therapeutic (deep heating) agent
stimulate tissue repair
pain relief

20. Transducer electric current delivered to crystal
crystal vibrates to create sound wave
Crystal is very important – changes electrical energy to acoustic energy
Crystal compresses and relaxes repeatedly in order to create acoustic wave impulses – depending on what mode you choose there may be a pulse of continuous current
PIEZOELECTRIC crystal

21. Energy Characteristics
Ultrasound tends to penetrate tissue easily that has high water content
Absorbed easily by tissues that are high in protein
Reflected a lot by boney tissue – if transducer is not constantly moved the bone will reflected the bone back and interact with another incoming wave – these waves can collide, heat up, and burn the patient
3Mhz tissue will heat up tissue faster to cause greater elasticity of a tissue – ex: 3Mhz on an Achilles tendon immediate heating of the tissue and can be stretched out right away
But 1Mhz heat penetrates deeper into the tissues – ex: used on quads and hams

22. Ultrasound
Ultrasound tends to penetrate tissue easily that has high water content Absorbed easily by tissues that are high in protein Reflected a lot by boney tissue – if transducer is not constantly moved the bone will reflected the bone back and interact with another incoming wave – these waves can collide, heat up, and burn the patient 3Mhz tissue will heat up tissue faster to cause greater elasticity of a tissue – ex: 3Mhz on an Achilles tendon immediate heating of the tissue and can be stretched out right away But 1Mhz heat penetrates deeper into the tissues – ex: used on quads and hams

23. Frequency greater the frequency, less the depth of penetration
superficial condition?
3MHz
deeper injuries?
1 MHz

24. Frequency greater the frequency, less the depth of penetration
greater the frequency, faster the tissue is heated

25. Intensity
rate at which energy is delivered, per unit area (of sound head)
measured in W/cm2
use lowest intensity of u/s energy at highest frequency which will transmit energy to specific tissue

26. Application Continuous Pulsed Continuous: continuous burst
Provides more thermal/heating effects with the constant waves entering
It is still possible to have non-thermal continuous – lower intensity!
Pulse: burst, break, burst, break
Provides more healing effects, slight increase in MR, BF
Cavitations occurs with both pulsed and continuous
But can be less controlled during pulse
Pulsed

27. Application Pulse period Pulse duration Duty cycle on time + off time
% time u/s is being generated during one pulse period

28. Pulsed u/s Pulsed u/s Average intensity over time is reduced
A way to get non-thermal effects without heating

29. Thermal Effects Increase of: 1° C -  metabolism and healing
2-3° C -  pain and spasm
4° C and above -  extensibility of collagen,  joint stiffness

30. Non-thermal effects cavitation
formation of bubbles that expand and contract
 flow in fluid around vibrating bubbles

31. Contraindications
not applied near eyes, heart, testicles or pregnant uterus
not over areas of decreased sensation or decreased vascularity
not applied over active epiphyseal plates

32. Application

33. Decision making depth of injury site desired effect intensity
1 MHz or 3 MHz?
desired effect
thermal or non- thermal effects?
pulsed or continuous?
intensity
treatment time

34. Phonophoresis
u/s used to drive molecules of a topically applied medication into the tissues
anti-inflammatory, ex. Hydrocortisone (pensaid)
tendinitis, bursitis
anesthetics, ex. lidocaine
trigger points

35. Phonophoresis medication rubbed into skin over treatment area
thermal effect of u/s increases tissue permeability
acoustic pressure of u/s beam drives medication into tissues

36. Electrical Stimulating Currents
create muscle contraction by nerve or muscle stimulation
stimulate sensory nerves to treat pain
drive ions beneficial for healing through the skin
create an electrical field in tissue to stimulate healing process
Sensory nerves, motor nerves, and those nerves that response to noxious stimuli

37. Electrical Stimulating Currents
as current intensity or duration is increased:
sensory effect
“pins and needles” or “tapping” sensation from stimulation of sensory nerves close to electrodes
motor effect
 motor neurons stimulated to create isometric or concentric muscle actions
noxious stimulation

40. Muscle Stimulation muscle strengthening* retardation of atrophy
muscle re-education
muscle “pump” contractions
reducing swelling
increasing ROM

41. Muscle Stimulation

42. Electrode Location

43. Electrode Location

44. Contraindications known or suspected cardiac arrhythmias pacemakers
severely obese
pregnancy
externally fixated fractures
over the carotid sinus

45. Sensory Nerve Stimulation
TENS – trans-cutaneous electrical nerve stimulation
maximally stimulate the sensory nerve fibers without stimulating the motor or pain fibers
to control acute and chronic pain

46. Effects??
stimulate large diameter sensory fibers to block pain impulses from ascending tracts of spinal cord
stimulate large diameter sensory fibers to produce endorphins, inhibiting pain transmission in ascending tracts

47. Effects??
stimulation of areas of brain stem activates descending efferent fibers in spinal cord, causing release of endorphins
inhibits transmission of impulses to ascending tracts
pain perception influenced by emotions, previous experience

48. Effects?? beta endorphin release ACTH release
corticosteroid release from adrenal glands

49. Current Parameters Modulation continuous interrupted burst ramped
Continuous – tend to get used to this stimulation the most
Interrupted –

50. Current Parameters frequency number of pulses per second
tapping  pins and needles
Lower frequency will provide more of a muscle contraction – potential for increased pain – but have a higher endorphin release
Higher Frequency – pain relief but effects are not as long lasting
Lower frequency (1-10, 1-50hz) will provide more of a muscle contraction
Potential for increase pain and higher endorphin release
Higher freq. Pain relief, but the healing effects wont be as long lasting.

51. IFC IFC – interferential Current
Electrodes placed in a square alignment and interferential currents are passed though a homogeneous medium , a predictable pattern of interference will occur
Resembles a four petal flower , with max interference taking place in the middle of the flower , and decreasing as we move outwards

52. IFC
However we are not a homogeneous medium , so we cannot perdict the exact interference point , , need help of the patient
We want the max effect at the area of the patients discomfort, poorly localized pain makes this harder to do , we can add in a scan feature which broadens the treatment area

53. Electrode Location (IFC)

54. IFC Pain higher pps ( 50 – 120 ) Swelling lower pps ( 10 – 50 )
Pain management – gate therapy , endorphins
Swelling – pulsing , pumping effect , movement of the current through the injured area